Citation Nr: 0215870
Decision Date: 11/06/02 Archive Date: 11/14/02
DOCKET NO. 99-15 559 ) DATE
)
)
On appeal from the
Department of Veterans Affairs Regional Office in Cleveland,
Ohio
THE ISSUE
Entitlement to an increased rating for rheumatic heart
disease, currently evaluated as 10 percent disabling.
REPRESENTATION
Appellant represented by: Disabled American Veterans
WITNESS AT HEARING ON APPEAL
Appellant
ATTORNEY FOR THE BOARD
J. A. McDonald, Counsel
INTRODUCTION
The veteran served on active military duty from February 1953
to October 1954. This case comes before the Board of
Veterans' Appeals (Board) on appeal from a rating decision of
the Department of Veterans Affairs (VA) Regional Office in
Cleveland, Ohio (RO).
The veteran's representative raised the issue of entitlement
to service connection for arteriosclerotic heart disease on a
secondary basis, as being aggravated by the veteran's
service-connected rheumatic heart disease. This issue has
not been adjudicated by the RO, and therefore, it is referred
to the RO for appropriate disposition.
FINDING OF FACT
1. The veteran's rheumatic heart disease is not manifested
by workload is not limited to between 5 and 7 metabolic
equivalents (METs), and this disease is not productive of
dyspnea, angina, dizziness, syncope, evidence of cardiac
hypertrophy or cardiac dilation.
2. Rheumatic heart disease is not productive of any
functional impairment.
CONCLUSION OF LAW
The criteria for a rating in excess of 10 percent for
rheumatic heart disease have not been met. 38 U.S.C.A.
§§ 1155, 5103A (West 1991 and Supp. 2002); 38 C.F.R.
§§ 3.102, 3.159, 3.326, 4.104, Diagnostic Code 7000 (2002).
REASONS AND BASES FOR FINDINGS AND CONCLUSION
Initially, the Board notes that the Veterans Claims
Assistance Act of 2000 was signed into law in November 2000.
See 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126
(West Supp. 2002). Following the RO's decision in the
veteran's claim, VA issued regulations implementing the
Veterans Claims Assistance Act. 38 C.F.R. §§ 3.102,
3.156(a), 3.159 and 3.326.
The veteran has been provided with numerous VA examinations
in connection with the issue on appeal. The record reflects
that the veteran has been informed of the requirements for
establishing an increased rating, and he has submitted
pertinent evidence in support of this claim.
The Board finds that the statement and supplemental statement
of the case provided the veteran with adequate notice of what
the law requires to award entitlement to an increased rating
for rheumatic heart disease. The veteran further was
provided adequate notice that VA would help him secure
evidence in support of this claim if he identified that
evidence. Additionally, he was provided notice of, and he
reported for, VA examinations. The statement and
supplemental statement of the case also provided notice to
the veteran of what the evidence of record, to include the VA
examinations, revealed. Additionally, they provided notice
of what the remaining evidence showed, including any evidence
identified by the veteran.
Finally, these documents provided notice why the RO concluded
that this evidence was insufficient to award a rating in
excess of 10 percent for rheumatic heart disease, as well as
notice that the veteran could still submit supporting
evidence. Thus, the veteran has been provided notice of what
VA was doing to develop the claim, notice of what he could do
to help his claim, and notice of how his claim was still
deficient. Furthermore, the RO complied with a Board remand
dated in December 2000. Because no additional evidence has
been identified by the veteran as being available but absent
from the record, the Board finds that any failure on the part
of VA to further notify him what evidence would be secured by
VA and what evidence he should secure is harmless. Cf.
Quartuccio v. Principi, 16 Vet. App. 183 (2002).
The veteran's service medical records show that he was
hospitalized in service for rheumatic fever with cardiac
manifestations. Subsequent to service discharge, a heart
murmur and shortness of breath with weight loss was reported.
An electrocardiogram and x-rays performed in 1955 were
normal. In March 1955, service connection for inactive
rheumatic heart disease, with valvulitis, was granted, and a
10 percent disability rating was assigned.
In 1958, a blowing systolic murmur was found on VA
examination; an electrocardiogram was within normal limits.
Thereafter in 1978, a private medical record reported that
borderline voltage criteria for left ventricular hypertrophy
was shown on an electrocardiogram. In January 1980, an
electroencephalogram was abnormal due to the occurrence of
frequent bitemporal sharp wave activity, more often seen on
the right side. The abnormality was described as
nonspecific. A private medical report dated in 1983, found a
pansystolic murmur, Grade II/III. A diastolic murmur was not
heard. The point of maximal impulse was palpable at the
fifth intercostal space in the midclavicular line.
Disability ratings are intended to compensate reductions in
earning capacity as a result of the specific disorder. 38
U.S.C.A. § 1155; 38 C.F.R. Part 4 (2002). In considering the
severity of a disability it is essential to trace the medical
history of the veteran. 38 C.F.R. §§ 4.1, 4.2 (2002).
Consideration of the whole recorded history is necessary so
that a rating may accurately reflect the elements of
disability present. Id.; Peyton v. Derwinski, 1 Vet. App.
282 (1991). While the regulations require review of the
recorded history of a disability by the adjudicator to ensure
a more accurate evaluation, the regulations do not give past
medical reports precedence over the current medical findings.
Accordingly, where an increase in the disability rating is at
issue, the present level of the veteran's disability is the
primary concern. Francisco v. Brown, 7 Vet. App. 55, 58
(1994).
The veteran filed a claim for an increased rating in December
1998.
Private medical records from 1996 to 1998, show diagnoses of
rheumatic heart disease with mitral insufficiency and aortic
insufficiency. Normal sinus rhythm was shown on examination,
as was a Grade II systolic murmur and an early diastolic
murmur. In May 1998, an electrocardiogram revealed a
borderline left ventricular hypertrophy.
VA outpatient treatment records dated in 1998 and 1999,
recorded complaints of left sided chest pressure and pain,
with shortness of breath on exertion. An electrocardiogram
conducted in December 1998, found left atrial enlargement and
normal sinus rhythm.
The veteran reported chest pains for the previous two years
that resolved with rest at a VA examination conducted in
February 1999. Symmetrical breath sounds were noted, with
normal inspiratory and expiratory components, and normal
diaphragmatic function with good air entry. A Grade II/IV
holosystolic murmur was noted at the base that radiated to
the axilla. A diastolic rumble was also noted at the apex,
and a S-4 gallop and an opening snap were also appreciated at
the base. Peripheral edema was not found and peripheral
pulses were 3+ symmetric, bilaterally, and include carotid,
brachial, radial, femoral, popliteal, and dorsalis pedis
pulses.
An electrocardiogram revealed a sinus bradycardia, with a
ventricular rate of 53, left ventricular hypertrophy, and
nonspecific ST, T wave changes. Stress testing revealed a
normal maximal exercise test, with 85% of target rate
reached, and 10 metabolic equivalents were achieved. Good
average physical work activity was reported, with normal ST
segments at rest and during exercise. No angina or
arrhythmias were provoked.
Echocardiography revealed normal exercise function, with no
definitive wall motion abnormalities to suggest significant
ischemic heart disease. There was moderate aortic
insufficiency noted at rest. The diagnosis was moderate
aortic insufficiency, secondary to rheumatic fever suffered
while on active duty. The examiner opined that the veteran's
ongoing symptomatology were the residuals of rheumatic heart
disease compatible with current findings. The examiner
further noted that there was no ongoing evidence on
examination, either by physical examination, resting
electrocardiograph, or stress echocardiography, to suggest
atherosclerotic heart disease as the etiology of the
veteran's ongoing complaints.
In May 1999, however, the veteran underwent stent placement
for a left anterior descending artery and left circumflex
artery lesions. Cardiac catheterization in November 1999,
found both the left anterior descending artery and left
circumflex artery in-stent re-stenosis. In January 2000, the
veteran underwent a three vessel bypass. Postoperative
diagnosis was atherosclerotic cardiovascular disease, with
unstable angina. A private medical report dated in February
2000, indicated that on examination, the veteran's heart had
regular rate and rhythm, with a Grade III/VI systolic
ejection murmur which was noted pre-operatively and was
unchanged. His lungs were clear to auscultation.
The veteran testified before the Board in April 2000, that
prior to the surgery, he had daily heart palpitations either
on exertion or at night. He also reported pain, dizziness,
fatigue, and shortness of breath that began in about 1996.
The veteran noted that since the surgery, the pressure
subsided, but his chest was numb and he still experienced
heart palpitations.
A November 2001 VA examination noted a history of rheumatic
fever in 1954. In May 1999, the veteran underwent cardiac
catheterization and stent placement, which subsequently
collapsed. In January 2000, the veteran had a cardiac
catheterization which revealed three-vessel coronary artery
disease, and he underwent three-vessel coronary artery bypass
grafting. Subsequently, the veteran was treated in cardiac
rehabilitation for 12 weeks. The veteran reported he was
able to walk approximately a mile on level grade in normal
weather at a slow pace, and climb one flight of stairs,
without any symptomatology. The veteran related that he had
chest pain intermittently since his surgery, but the chest
pain was not similar to that previously called angina.
Rather, the pain was described as a numb sensation in his
chest. The veteran stated that he previously had been able
to walk and mow his lawn, but now experienced chest
discomfort and his legs weakened. The examiner noted that
the veteran did not have surgical intervention for aortic
insufficiency in January 2000. It was reported that
postoperatively the veteran developed a tremor and
Parkinson's disease. The veteran had a history of
hypercholesterolemia, hypertriglyceridemia, and smoking.
Cardiopulmonary examination revealed symmetric breath sounds,
with normal inspiratory and expiratory components, and a
normal diaphragmatic function with good air entry. A Grade
II/VI holosystolic murmur was noted at the base, and radiated
to the axilla. A diastolic rumble was noted at the base, and
a S4 gallop and opening snap were also appreciated at the
base. No peripheral edema was noted. Peripheral pulses were
3+ and symmetric, bilaterally, and included carotid,
brachial, radial, femoral, popliteal, and dorsalis pedis
pulses.
Lower arterial Doppler studies revealed triphasic waveforms
from the common femoral to the more distal posterior tibial
and dorsalis pedis arteries, bilaterally. The ankle-brachial
indices were within normal limits and there was no evidence
of arterial vascular occlusive disease. An electrocardiogram
revealed marked sinus bradycardia, and left ventricular
hypertrophy, with QRS widening in an abnormal
electrocardiogram. Echocardiographic studies revealed mild
aortic stenosis, mild aortic insufficiency, left atrial
dilatation, mild to moderate degree of mitral regurgitation,
and mild tricuspid regurgitation. Left ventricular systolic
function was normal.
There was a markedly submaximal exercise test by
electrocardiogram criteria. The examiner noted that the
veteran's beta blocker therapy might have effected the
sensitivity of the test. Forty-two percent of the target
heart rate was reached. Physical work capacity was low at
1.7 metabolic equivalents achieved. No angina was provoked
by exercise and there were normal ST segments at rest during
exercise. A single premature ventricular contraction was
provoked by exercise.
The examiner concluded that the veteran's proper diagnoses
were atherosclerotic heart disease, status post coronary
artery bypass grafting, New York State Heart Association
Class III; aortic stenosis, aortic insufficiency secondary to
rheumatic fever; left ventricular hypertrophy secondary to
hypertension; and mild tricuspid regurgitation. The examiner
stated that the veteran had recurrent chest pain and
exertional dyspnea, but no functional impairment was found
secondary to his service-connected rheumatic heart disease.
The examiner further opined that
the veteran's increased symptomatology
related to cardiac-related problems is
secondary to atherosclerotic heart
disease. There is no current evidence to
suggest that the veteran's rheumatic
cardiac disease (aortic stenosis, aortic
insufficiency) have in any way
contributed or caused the veteran's
current symptomatology.
The veteran has preserved left
ventricular end-diastolic and systolic
function. While there is left
ventricular hypertrophy, this is
secondary to hypertension and not likely
related to the veteran's mild aortic
stenosis. The veteran had a valve
surface area of 1.8 cm2 and these
findings were consistent with a mild
degree of aortic stenosis and aortic
regurgitation and not considered
operable. The veteran's mild to moderate
degree of mitral regurgitation, while
noted, is mild at best and also not
indicative of a problem that causes the
veteran's symptomatology nor a problem
that led to the veteran's coronary artery
bypass grafting.
The examiner stated that the risk factors for the veteran's
atherosclerotic heart disease included male gender,
hypertension, hypercholesterol/triglyceridemia, and remote
tobacco use. The examiner opined that there was less than a
50 percent probability that the veteran's rheumatic heart
disease aggravated his atherosclerotic heart disease beyond
normal progression. Historically, the veteran's baseline
manifestation of atherosclerotic heart disease was chest
pain. The examiner concluded that "there is no
manifestation that is proximately due to the veteran's
service-connected rheumatic heart disease (i.e., it is the
opinion of this examiner that the veteran's atherosclerotic
heart disease would exist independent of his rheumatic heart
disease)."
The veteran's service-connected rheumatic heart disease is
currently rated 10 percent disabling under the provisions of
38 C.F.R. § 4.104, Diagnostic Code 7000. This rating
contemplates valvular heart disease with a workload of
greater than 7 metabolic equivalents but not greater than 10
metabolic equivalents resulting in dyspnea, fatigue, angina,
dizziness or syncope, or continuous medication required. A
30 percent rating is warranted with a workload of greater
than 5 metabolic equivalents but not greater than 7 metabolic
equivalents, that results in dyspnea, fatigue, angina,
dizziness, or syncope, or; evidence of cardiac hypertrophy or
dilatation on electrocardiogram, echocardiogram, or x-ray.
38 C.F.R. § 4.104, Diagnostic Code 7000.
In the instant case, a rating in excess of 10 percent for
rheumatic heart disease is not warranted. Evidence of a
decreased workload of less than 7 metabolic equivalents due
to rheumatic heart disease has not been shown, nor has
evidence of cardiac hypertrophy or dilatation on
electrocardiogram, echocardiogram, or x-ray been shown to be
due to rheumatic heart disease. Although a VA examination
conducted in November 2001, found the veteran's physical work
capacity was only 1.7 metabolic equivalents, the examiner
concluded that this was due to his nonservice connected
arteriosclerotic heart disease, and not due to his service-
connected rheumatic heart disease. Additionally, the
examiner concluded that left ventricular hypertrophy were
secondary to hypertension and not likely related to the
veteran's mild aortic stenosis.
VA Adjudication Manual, M21-1, Part VI, Chapter 5, paragraph
11.18f(2) (August 26, 1996) states that "if verified
rheumatic heart disease has been demonstrated, the effect of
subsequent onset of hypertensive or arteriosclerotic heart
disease which may also produce heart muscle changes and
congestive failure cannot be satisfactorily dissociated from
the rheumatic changes." The combined cardiac disability is
to be evaluated as one entity under the service-connected
rheumatic heart disease code. In May 2000, the VA General
Counsel held that this provision of M21-1 is substantive and
binding on the Board. VAOPGCPREC 6-2000 (May 19, 2000).
Following this opinion the manual provisions were changed in
December 2000 to require a medical opinion as to whether the
effects of service-connected rheumatic heart disease and
subsequently developing arteriosclerotic heart disease can be
separated. The latter condition is to be rated as part and
parcel of the former, only if the effects of each cannot be
separated.
The November 2001 examiner stated that the veteran's
increased cardiac-related symptomatology was secondary to
atherosclerotic heart disease. The examiner further opined
that rheumatic cardiac disease did not contribute or cause
the symptomatology. Accordingly, the examiner separated the
effects of the veteran's service-connected heart disorder
from his nonservice-connected disorder, and therefore, the
disabilities are not to be evaluated as one entity under the
service-connected rheumatic heart disease code.
Accordingly, the Board finds that manifestations of the
veteran's rheumatic heart disease include aortic stenosis and
aortic insufficiency which results in no functional
impairment. Findings were consistent with a mild degree of
aortic stenosis and aortic regurgitation. The veteran's
degree of mitral regurgitation, was noted as mild at best.
Accordingly, a rating in excess of 10 percent for rheumatic
heart disease is not warranted.
In reaching this decision the Board considered the doctrine
of reasonable doubt, however, as the preponderance of the
evidence is against the veteran's claim, the doctrine is not
for application. Gilbert v. Derwinski, 1 Vet. App. 49
(1990).
ORDER
An increased rating for rheumatic heart disease is denied.
DEREK R. BROWN
Member, Board of Veterans' Appeals
IMPORTANT NOTICE: We have attached a VA Form 4597 that tells
you what steps you can take if you disagree with our
decision. We are in the process of updating the form to
reflect changes in the law effective on December 27, 2001.
See the Veterans Education and Benefits Expansion Act of
2001, Pub. L. No. 107-103, 115 Stat. 976 (2001). In the
meanwhile, please note these important corrections to the
advice in the form:
? These changes apply to the section entitled "Appeal to
the United States Court of Appeals for Veterans
Claims." (1) A "Notice of Disagreement filed on or
after November 18, 1988" is no longer required to
appeal to the Court. (2) You are no longer required to
file a copy of your Notice of Appeal with VA's General
Counsel.
? In the section entitled "Representation before VA,"
filing a "Notice of Disagreement with respect to the
claim on or after November 18, 1988" is no longer a
condition for an attorney-at-law or a VA accredited
agent to charge you a fee for representing you.